Patterns of benzodiazepine prescribing by neuropsychiatrists and general practitioners for elderly patients in Germany in 2014
.

BACKGROUND: The patterns of benzodiazepine prescriptions in older adults are of general and scientific interest as they are not yet well understood. The aim of this study was to compare the prescription patterns of benzodiazepines in elderly people in Germany to determine the share or proportion treated by general practitioners (GP) and neuropsychiatrists (NP). METHODS: This study included 31,268 and 6,603 patients between the ages of 65 and 100 with at least one benzodiazepine prescription in 2014 from GP and NP, respectively. Demographic data included age, gender, and type of health insurance coverage. The share of elderly people with benzodiazepine prescriptions was estimated in different age and disease groups for both GP and NP patients. The share of the six most commonly prescribed drugs was also calculated for each type of practice. RESULTS: The share of people taking benzodiazepines prescribed by GP increased from 3.2% in patients aged between 65 and 69 years to 8.6% in patients aged between 90 and 100 years, whereas this share increased from 5.4% to 7.1% in those seen by NP. Benzodiazepines were frequently used by patients suffering from sleep disorders (GP: 33.9%; NP: 5.5%), depression (GP: 17.9%; NP: 29.8%), and anxiety disorders (GP: 14.5%; NP: 22.8%). Lorazepam (30.3%), oxazepam (24.7%), and bromazepam (24.3%) were the three most commonly prescribed drugs for GP patients. In contrast, lorazepam (60.4%), diazepam (14.8%), and oxazepam (11.2%) were those more frequently prescribed to NP patients. CONCLUSION: Prescription patterns of benzodiazepine in the elderly varied widely between GP and NP.
.

Twitter psychosis: a rare variation or a distinct syndrome?

The authors report the development of psychosis in a young woman coinciding with excessive use of the online communication system Twitter and the results of an experimental account to argue that Twitter may have a high potential to induce psychosis in predisposed users.

Agitation in nursing home residents with dementia (VIDEANT trial): effects of a cluster-randomized, controlled, guideline implementation trial.

OBJECTIVE: To test the effect of a complex guideline-based intervention on agitation and psychotropic prescriptions. DESIGN, SETTING, PARTICIPANTS: Cluster randomized controlled trial (VIDEANT) with blinded assessment of outcome in 18 nursing homes in Berlin, Germany, comprising 304 dementia patients. INTERVENTION: Training, support, and activity therapy intervention, delivered at the level of each nursing home, focusing on the management of agitation in dementia. Control group nursing homes received treatment as usual. MEASUREMENTS: Levels of agitated and disruptive behavior (Cohen-Mansfield agitation inventory [CMAI]) as the primary outcome. Number of neuroleptics, antidepressants, and cholinesterase inhibitors (ChEIs) prescribed in defined daily dosages (DDDs). RESULTS: Of 326 patients screened, 304 (93.3%) were eligible and cluster-randomized to 9 intervention (n = 163) and 9 control (n = 141) nursing homes. Data were collected from 287 (94.4%) patients at 10 months. At 10 months, compared with controls, nursing home residents with dementia in the intervention group exhibited significantly less agitation as measured with the CMAI (adjusted mean difference, 6.24; 95% CI 2.03-14.14; P = .009; Cohen's d = 0.43), received fewer neuroleptics (P < .05), more ChEIs (P < .05), and more antidepressants (P < .05). CONCLUSION: Complex guideline-based interventions are effective in reducing agitated and disruptive behavior in nursing home residents with dementia. At the same time, increased prescription of ChEIs and antidepressants together with decreased neuroleptic prescription suggests an effect toward guideline-based pharmacotherapy.

Decline in prefrontal catecholamine synthesis explains age-related changes in cognitive speed beyond regional grey matter atrophy.

PURPOSE: Age-related decline in cognitive speed has been associated with prefrontal dopamine D1 receptor availability, but the contribution of presynaptic dopamine and noradrenaline innervation to age-related changes in cognition is unknown. METHODS: In a group of 16 healthy participants aged 22-61 years, we used PET and the radioligand FDOPA to measure catecholamine synthesis capacity (K (in) (app); millilitres per gram per minute) and the digit symbol substitution test to measure cognitive speed, a component of fluid IQ. RESULTS: Cognitive speed was associated with the magnitude of K (in) (app) in the prefrontal cortex (p < 0.0005). Both cognitive speed (p = 0.003) and FDOPA K (in) (app) (p < 0.0005) declined with age, both in a standard voxel-wise analysis and in a volume-of-interest analysis with partial volume correction, and the correlation between cognitive speed and K (in) (app) remained significant beyond the effects of age (p = 0.047). MR-based segmentation revealed that these age-related declines were not attributable to age-related alterations in grey matter density. CONCLUSION: Our findings indicate that age-related changes in the capacity of the prefrontal cortex to synthesize catecholamines, irrespective of cortical atrophy, may underlie age-related decline in cognitive speed.

Correlates of agitation and depression in nursing home residents with dementia.

BACKGROUND: The purpose of this study was to investigate the relationship between dementia severity, age, gender, and prescription of psychotropics, and syndromes of agitation and depression in a sample of nursing home residents with dementia. METHODS: The Cohen-Mansfield Agitation Inventory (CMAI) was administered to residents with dementia (N = 304) of 18 nursing homes. Agitation symptoms were clustered using factorial analysis. Depression was estimated using the Dementia Mood Assessment Scale (DMAS). Dementia severity was assessed categorically using predefined cut-off scores derived from the Mini-Mental State Examination (MMSE). The relationship between agitation and its sub-syndromes, depression, and dementia severity was calculated using χ 2-statistics. Linear regression analyses were used to calculate the effect of dementia severity and psychotropic prescriptions on agitation and depression, controlling for age and gender. RESULTS: Increasing stages of dementia severity were associated with higher risk for physically aggressive (p < 0.001) and non-aggressive (p < 0.01) behaviors, verbally agitated behavior (p < 0.05), and depression (p < 0.001). Depressive symptoms were associated with physically aggressive (p < 0.001) and verbally agitated (p < 0.05) behaviors, beyond the effects of dementia severity. Prescription of antipsychotics was correlated with depression and all agitation sub-syndromes except hiding and hoarding. CONCLUSIONS: Dementia severity is a predictor for agitation and depression. Beyond that, depression increased with dementia severity, and the severity of depression was associated with both physically and verbally aggressive behaviors, indicating that, in advanced stages of dementia, depression in some patients might underlie aggressive behavior.

The pharmacotherapy of neuropsychiatric symptoms of dementia: a cross-sectional study in 18 homes for the elderly in Berlin.

BACKGROUND: The neuropsychiatric symptoms of dementia, including aggressiveness, agitation, depression, and apathy are often treated with psychotropic drugs and are a frequent reason for hospitalization, placing an economic burden on the health care system. International guidelines recommend syndrome-specific pharmacotherapy. We studied the question whether drug-prescribing practices are, in fact, syndrome-specific. METHODS: In a cross-sectional study in 18 homes for the elderly in Berlin, we used syndrome-specific scales to determine the prevalence of apathy, depression, and aggressiveness and the quantity of psychotropic drugs prescribed, in defined daily dosages (DDD), among 304 demented inhabitants. The diagnosis of dementia was ascertained by chart review and confirmed by administration of a mini mental status test. RESULTS: More than 90% of the demented patients had neuropsychiatric symptoms, most commonly apathy (78%). 52% were treated with neuroleptic drugs, 30% with antidepressants and 17% with anti-dementia agents. There was no significant difference between the frequency of neuroleptic treatment given to apathetic and depressed patients and that given to aggressive patients (chi(2) = 7.03; p = 0.32). CONCLUSION: Although our sample of patients was not representative, these findings suggest that neuropsychiatric symptoms in demented patients are not being treated in syndrome-specific fashion. This is troubling, because neuroleptic medications administered to demented patients can have serious adverse effects, including an elevated mortality. The German guidelines for the treatment of neuropsychiatric disturbances were recently published; the findings presented here suggest that their implementation would be advantageous.

Adjunct treatment with levodopa in a patient with dementia with Lewy bodies, delusions and severe neuroleptic hypersensitivity syndrome.

We report on the treatment of a patient suffering from dementia with Lewy bodies who initially presented with severe neurological and psychopathological symptoms. After treating the patient with levodopa and clozapine, these symptoms remitted.

[Pharmacotherapy of neuropsychiatric symptoms in dementia in nursing homes: a comparison of service provision by psychiatric outpatient clinics and primary care psychiatrists]. / Pharmakotherapie von neuropsychiatrischen Symptomen bei Demenz in Altenpflegeheimen: Ein Vergleich der Versorgung durch psychiatrische Institutsambulanzen und niedergelassene Fachärzte.

BACKGROUND: Neuropsychiatric symptoms of dementia like agitation, depression and apathy often result in increased prescriptions of psychotropics. In Germany, outpatient clinics at psychiatric hospitals play an important role in the treatment of neuropsychiatric symptoms in nursing homes. The aim of this study was to test whether the severity and pharmacotherapy differed in patients treated by outpatient clinics at psychiatric hospitals, as compared to primary care specialists. METHODS: A cross-sectional study of the prevalence of agitation, apathy, and depression, and the amount of psychotropics prescribed in defined daily dosages (DDD) in 304 residents with dementia in 18 Berlin nursing homes. RESULTS: Patients treated by outpatient clinics at psychiatric hospitals suffered from more severe neuropsychiatric symptoms (p < 0.05), were prescribed more antidepressants and antidementia agents (p < 0.05) and, when adjusting for the severity of agitation, less neuroleptics (p < 0.05) as compared to primary care specialists. CONCLUSION: Psychiatric outpatient clinics at hospitals treat more severely demented patients who suffer from severe neuropsychiatric symptoms. The pharmacotherapy provided by these clinics displays a favourable profile according to established treatment guidelines.

Altered function of ventral striatum during reward-based decision making in old age.

Normal aging is associated with a decline in different cognitive domains and local structural atrophy as well as decreases in dopamine concentration and receptor density. To date, it is largely unknown how these reductions in dopaminergic neurotransmission affect human brain regions responsible for reward-based decision making in older adults. Using a learning criterion in a probabilistic object reversal task, we found a learning stage by age interaction in the dorsolateral prefrontal cortex (dlPFC) during decision making. While young adults recruited the dlPFC in an early stage of learning reward associations, older adults recruited the dlPFC when reward associations had already been learned. Furthermore, we found a reduced change in ventral striatal BOLD signal in older as compared to younger adults in response to high probability rewards. Our data are in line with behavioral evidence that older adults show altered stimulus-reward learning and support the view of an altered fronto-striatal interaction during reward-based decision making in old age, which contributes to prolonged learning of reward associations.

Role of ventral striatum in reward-based decision making.

So far, the specific role of the ventral striatum in reward-based decision making remains elusive. Here, we examined the role of the ventral striatum in reward-based decision making using functional MRI and a probabilistic object reversal task. During decision making, activity in the ventral striatum increased monotonically as a function of association learning and was greatest when the individuals expected to be rewarded for the decision with high certainty. Conversely, during the reward phase, activity in the ventral striatum showed an inverted U-shaped modulation by learning and was greatest when uncertainty about the outcome was maximal. Our data indicate that, during reward-based decision making, the ventral striatal signal dynamically changes over time dependent on the phase of the reward process and on the learning status and thereby acts as a motivational engine for the continuation of behavior.